Tagged: Provider Reimbursement Review Board

ADH’s client prevailed over Prince George’s County Hospital Center (PGHC) in a civil action over whether the client, a Medicaid Managed Care Organization (MCO), was liable to PGHC for care that PGHC provided to certain persons who claimed to be members of the MCO. PGHC failed to timely notify the MCO that the patients were potentially covered by the MCO, in many cases waiting until after the treatment had concluded. Because of PGHC’s failure to identify the patients as members in a timely manner, the MCO was precluded from managing the patients’ care and ensuring that the patients could be safely transferred to in-network medical care providers.

The primary questions in the case were: whether a hospital had the right to sue a Medicaid MCO directly and whether the hospital was an intended third party beneficiary of the MCO’s contract with the District of Columbia. The District Court initially permitted the claim to proceed on a third party beneficiary theory, but ADH sought reconsideration based on intervening Supreme Court precedent. The client prevailed because ADH was able to demonstrate that there was no private cause of action under the Statute and no intention to extend third party beneficiary status to medical providers in the Medicaid MCO contract.

ADH files suit on behalf of Forsyth Hospital, claiming that the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services breached the terms of a 2004 settlement agreement. For more information, please contact Les Alderman.

ADH settles Waterbury Hospital v. Sebelius for over $100,000 over allegations that the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, underpaid the hospital for its Medicare Cross-Over Bad Debt Claim and then the Provider Reimbursement Review Board incorrectly denied jurisdiction over the hospital’s appeal. For more information, please contact Les Alderman.

ADH files suit on behalf of dozens of hospitals claiming that the Provider Reimbursement Review Board, among other things, wrongfully dismissed and remanded their appeals, in violation of the law and the U.S. Constitution. For more information, please contact Les Alderman.

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